Health inspection·July 7, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death. The findings included: Record review of Resident #1's face sheet dated 6/24/2025 revealed a 72- year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and/or anxiety, unspecified pain and primary osteoarthritis left hand. Record review of Resident #1's significant change MDS dated [DATE] revealed a BIMs score could not be determined due to both long-term and short-term memory loss and severely impaired cognitive skills and inattention. The assessment indicated no behaviors exhibited with maximum to total dependance on staff for ADL care. Record review of Resident #1's care plan initialed on 10/21/2021 revealed the resident was full code status with interventions: in the event of cardiac or respiratory arrest, staff will perform cardiopulmonary resuscitation. ADL self-care performance deficit related to dementia, debility and muscle wasting with interventions which included maximal assistance to full dependance on ADL care of one staff person for all ADLs. A potential for pain related to dementia, impaired mobility and stiffness with an intervention of administer medications as ordered by physician. Record review of Resident #1's physician order summary for June 2025 revealed an order with a start date of 10/04/2021 for Lidoderm Patch 5% (Lidocaine) apply to left leg and right shoulder for pain, apply one patch to left leg and one patch to right shoulder, off at HS (bedtime). Record review of Resident #1's June 2025 MAR revealed Lidoderm Patch 5% (Lidocaine) was last documented as administered on the morning of 6/23/2025 by CMA A and last documented as removed by LVN C (time unknown). Record review of Resident #1's Lidoderm Patch 5% time/date CMA Administration Record audit report dated 7/03/2025 revealed: CMA A documented application of Lidoderm Patch 5% to right front shoulder on 6/23/2025 at 11:10 a.m. and LVN C documented handling (unknown handling) of the patch on 6/23/2025 at 7:46 p.m. Record review of Resident #1's nurse progress notes, LVN C documented she made rounds on Resident #1 at 12:57 a.m. and gave the resident acetaminophen. At 2:30 a.m., she documented she was summoned by a CNA, that the resident was not breathing. The residents code status was verified, CPR was initiated, checked the airway and AED was applied. EMS pronounced time of death at 2:49 a.m. and the ME office came to retrieve the body. Record review of form 3613-A Provider Incident Report dated 7/01/2025 revealed a facility self-reported incident that occurred on 6/24/2025 at Page 1 of 8 676250 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2:30 pm resulting in Resident #1's death, signed by the Executive Director. The supporting documents indicated an allegation was confirmed after investigation. The summary stated Resident #1 did not exhibit behaviors of putting foreign items or non-edible foods in her mouth. The report indicated the medical examiner's office verbally informed the facility that Resident #1 expired from accidental asphyxiation choking on 6/24/2025[PH3] . Record review of a witness statement by CMA A dated 6/24/2025, CMA A wrote on 6/23/2025 she administered Resident #1's routine medications and applied two patches to her left leg and to her right shoulder. She wrote Resident #1 appeared to be her normal state of condition. She also wrote she had never witnessed the resident put any object in her mouth. Record review of a written statement by CNA B dated 6/24/2025 revealed he last saw Resident #1 alive and breathing at 1:15 a.m[PH4] [SA5] .(6/24/25). At 2:15 a.m., he noticed the resident was unresponsive, called for a nurse and code and confirmed CPR was initiated and 911 was called. Record review of a written statement by LVN D dated 6/24/2025, LVN D wrote she saw LVN C running up the hallway asking for Resident #1's code status, which was full code. LVN C ran back to the resident room and CPR was initiated. She wrote when she got to the room, Resident #1 was already placed on the floor with a back board and AED in place. She (LVN D) got the ambu bag and connected to the oxygen tank and started breath resuscitation. Upon placing the mask to the resident's face, she noticed a white substance in the resident mouth. She wrote she did a finger sweep of the mouth but was unable to get the white substance out with glove. She wrote EMS arrived and took over. She wrote she assumed the white substance was thrush on her tongue. She wrote she was able to see the chest rise and fall with each breath resuscitation provided. Record review of a written statement by LVN C dated (undated), LVN C wrote on 6/24/2025 at 12:57 a.m. Resident #1 received acetaminophen and then at 2:30 a.m. she was summoned by a CNA (not named) for a change of condition. CPR initiated. She wrote she was doing chest compressions; the AED was initiated and LVN D began using the ambu bag and provided a finger sweep. LVN C wrote LVN D felt it looked like thrush. EMS arrived and took over. They used a suction machine and obtained a Lidoderm patch from Resident #1's mouth. EMS pronounced death at 2:49 a.m. and the medical examiners office came to retrieve her body. Record review of a written statement by LVN C dated 6/25/2025 revealed she was working as a CMA on 6/23/2025 and she took the patch (Lidoderm) to the knee but not to her shoulder. She wrote she did not see a patch on her shoulder. During an interview on 7/03/2025 at 10:37 a.m. CMA A stated she was the medication aide that applied the Lidocaine patch to Resident #1's right shoulder and left leg at approximately 11:00 a.m. on 6/23/2025. She stated she dated the patches with her initials. She stated she was not the same person who removes the patches, she only applies them. CMA A stated Resident #1 used the patches for pain on a routine schedule. She stated when she applied the patches, she looked for old ones and did not see any. CMA A stated she remembers physically putting the patches on the resident. She stated the right shoulder patch was placed on the top right shoulder in the front of the body. CMA A stated she was not working when Resident #1 died. She stated the resident could answer simple yes/no questions but could not make her needs known. She was wheelchair dependent and required staff to move the wheelchair for her. She stated she was not aware of any behaviors other than occasional yelling out. CMA A stated since the incident had occurred, she had completed multiple trainings. She stated the trainings included application of patch, removal and disposal of the patch. She stated now when a patch was removed the new training was for two staff the med aide and the nurse to go together to witness the removal and both have to document the removal. She stated she had also received training on CPR, what to do when they see someone choking which included the Heimlich maneuver. She stated she practiced in person the skills. She stated she had training about resident choking hazards and putting objects in their 676250 Page 2 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few mouths. She stated they are to keep out of reach and if they see a resident with something that was a choking hazard she should first attempt to take it away and then report immediately to the DON. She stated there were no residents with that behavior currently with known behaviors of putting objects in their mouth. CMA A stated she had received abuse and neglect training which included definitions. She stated neglect was not providing a resident with care, not feeding, or changing them or not answering the call light. She stated she was trained to report any abuse or neglect immediately and within 2 hours to the Abuse Coordinator who was the ED. During an interview on 7/03/2025 at 11:09 a.m., CNA B stated he worked on 6/23/2025-6/24/2025 on night shift. He stated his shift started at 10:00 p.m. He stated at the start of the shift he made rounds and Resident #1 was okay. CNA B stated at approximately 12:00 p.m., he changed her, and she was doing good. He stated she has dementia and would talk to herself at night but was not verbal and could not communicate. He stated the next round was at approximately 2:00-2:15 a.m. He stated he first changed Resident #1's roommate. He stated then he approached Resident #1 and saw she was unresponsive. He stated she was not breathing, and he could just tell she was not ok. He stated her body was warm and he did not notice anything visible outside of her mouth. He stated he immediately notified the nurse, LVN C and called a Code Blue. CNA B stated he stayed in the room with LVN C and LVN D to help with CPR until EMS arrived. He stated the nurses saw something in her mouth and thought it was thrush, he said they knew something was there. He said he could not really describe it. LVN D was using the bag (ambu bag used to provide ventilations during CPR) and he was performing chest compressions. He stated he did not know if Resident #1's chest had a rise and fall with respirations because he was doing compressions. He stated after EMS arrived while EMS was doing CPR, they found something in Resident #1's mouth and pulled it out with a Yanker (suction). He stated he did not know what it was. He stated he left the room at that point with EMS still working on the resident. CNA B stated he did not notice anything wrong or any change in Resident #1 prior to finding her unresponsive. He stated she required full staff assistance for all care. He stated this included feeding. CNA B stated Resident #1 was able to move her hands to her head and touch her hair, scratch her face, etc. but she did not have the cognitive status to be able to feed herself. He stated she was bedbound unless someone moved her or transferred her out of bed. CNA B stated Resident #1 was unable to use the call light and was unable to make her needs known. He stated to meet her needs they had to check on her and make rounds every two hours. CNA B stated Resident #1 did not have any behaviors of putting things in her mouth other than food on a plate in front of her. He stated she would pick up a cup in front of her and chew on it and he has seen her chew on her tongue. CNA B stated he had noticed patches on her body during the daytime but not at night. He stated he did not know what time the patches were normally taken off. CNA B stated before Resident #1 was found unresponsive he had noticed a patch on her inner shoulder. He stated he thought that patch wasn't where it normally goes but he did not say anything to anyone because he thought maybe somebody was going to come back and get it. CNA B stated after she was found unresponsive, he was not paying attention to patches and does not remember if the patch was still there or not. CNA B stated after the incident the facility did an investigation and he was asked the same questions he was asked today. He stated they received a lot of training. He stated the training was what to do in an emergency. He stated as a CNA they told him he could do CPR after notifying the nurse and verifying code status. He stated any staff could perform CPR until EMS arrived. He stated the in-service training included compressions, respirations, oxygen use, emergency procedures, how to use the bubble thing (ambu bag). He stated he received a choking and small object in-service. He stated they were told to immediately perform the Heimlich maneuver until the object was removed and CPR if necessary. 676250 Page 3 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Trained to keep small objects out of the reach of dementia residents. He stated he received training on notifying the nurse of small objects including patches. He stated he received abuse/neglect training. He stated he learned about the definition of neglect which was refusing to give care to a resident or not rendering aide. He stated he was not aware of any neglect at the facility. He stated he was trained to notify the Executive Director immediately. During an interview on 7/03/2025 at 1:43 p.m., LVN C stated on 6/24/2025 between 2:00-3:00 a.m., she was summoned by CNA B from the door of the resident room while she was near the nurse's station. She stated she was told it looked like Resident #1 had passed. LVN C stated she immediately asked LVN D to look up the resident's code status which was verified full code and immediately went to the room with CNA B. She stated Resident #1 was warm, was not breathing and had no signs of life. She stated they pulled Resident #1 to the floor and noted she was warm and began CPR. LVN C stated LVN D called 911 and then came to assist with CPR until EMS arrived. LVN C stated LVN D did the ambu bag. LVN C stated she noted something that looked like bubbles in Resident #1's mouth. She stated LVN D did a finger sweep and could not get anything out of the mouth. LVN C stated she did not suction the bubbles because they were able to get air through and into her and she had no color change, was not blue. LVN C stated the resident was pale. LVN C stated the resident had a rise and fall of the chest with ambu bag. She stated the reason a finger sweep was done because they saw the bubbles, they could see something, and they thought what was that? LVN C stated the had brought the crash cart and AED which was applied but did not suction because they were able to get the rise and fall of her chest. LVN C ended the interview at this time and stated she would continue later in the day. During an interview on 7/03/2025 at 3:25 p.m., LVN D stated she was seated at the desk on 6/24/2025 (time unknown) when LVN C came running up to her and asked her to look up code status for Resident #1. She stated she confirmed full code. LVN D stated she called 911 and then went to the room to assist. LVN D stated when she got to the room Resident #1 was on the floor and CNA A and LVN C were doing compressions. She stated she connected the ambu bag (to oxygen). She stated when she tilted Resident #1's head back to use the ambu bag she saw something white in her mouth. She stated she tried to remove it with her finger but could not get it out because it was so slippery. LVN D stated she gave Resident #1 breaths with the ambu bag and got a rise and fall of the chest. She stated she then again tried to remove the substance. She stated the substance was too slippery and she could not grab it. She stated at the same time EMS arrived and took over. LVN D stated she told EMS about the substance in her mouth. She stated EMS asked her for tweezers which she did not have. She stated EMS used the suction from the crash cart with a yanker (type of suction catheter). LVN D stated EMS tried to maneuver the white substance out of her mouth with the suction. She stated the EMS tech finally stuck his whole hand in her mouth and pulled out a white substance that was really gooey and slimy. LVN D stated she thought it looked like a mucous plug. LVN D stated EMS said this was what was in her throat but did not say what it was. LVN D stated she left the room after EMS took over to print paperwork for EMS. LVN D stated she did not normally work that hallway and was unfamiliar with Resident #1. LVN D stated she thought the facility emergency procedures weren't well. She stated they followed facility policy, worked together to notify 911, and do CPR. She stated someone (unknown name) went and held open the front door for EMS personnel who arrived very fast. LVN D stated after the incident she received multiple trainings. She stated she had to perform a demonstration and check off of how to properly put on and take off a patch, how to dispose of it in a trash can with stick sides pressed together and outside of the resident room. She stated she was trained that if they see any object in a residents mouth, they are to notify the DON right away, keep objects out of reach. She stated received CPR, Heimlich training and abuse training. 676250 Page 4 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She stated she was instructed where the Abuse Coordinator number was located which was all over the place and to notify him (ED) immediately. During an interview on 7/03/2025 at 3:40 p.m., CMA E stated Resident #1 normally had her shoulder Lidoderm in the front and not in the back. She stated she was not working on the date of the incident. She stated she was not aware of any behaviors of putting objects in the mouth by Resident #1 or any other resident. She stated while working she had never had an incident where one of Resident #1's patches was missing. She described Resident #1 as very confused and unable to say what she needed. CMA E stated following the incident she had received in-service training which included patches, how to put on and take off. She stated two people, one being a nurse had to witness removal of patches. She stated all patches had to be disposed of in the medication cart and not in a resident room and had to be signed off with the nurse. She stated she also received training on CPR, first aide, small objects. She stated she was trained to notify the nurse of objects. And if a resident was choking to initiate the choking protocol, CPR and call 911. She stated during CPR she was trained to call 911, get the crash cared, open doors for EMS and to assist wherever was needed. She stated she did a demonstration for CPR and choking. She stated she had received abuse/neglect training, had no knowledge of any resident abuse or neglect and new to tell the ED immediately. During an interview on 7/03/2025 at 4:02 p.m. LVN C stated Resident #1's Lidoderm patches were applied in the morning and taken off in the evening by the medication aides. She stated she worked the medication aide cart on 6/23/2025 and acknowledged she signed off that the patches in the evening. LVN C stated she removed the one from the left knee but did not see a patch on Resident #1's shoulder to remove. She stated this occurred at approximately 7:00 pm. She stated she looked for the patch on the back of the shoulder and on the arm and did not see it. She stated she did not know where the patch was normally placed on Resident #1 because she normally did not pass the medications. She stated she looked on the resident back but not on her from and not on her chest. She stated she did look on the front of the shoulder but not the chest area. LVN C stated she assumed the Lidoderm patch fell off. She stated Again, I don't know. I don't normally pass the medications when asked how she trained to respond when a patch could not be located. LVN C stated all she knew was that the patch would normally be taken off in the evening. LVN C stated Resident #1 did not have behaviors. She stated the resident would babble to herself until she fell asleep, and night and she never saw her chew on anything or put anything in her mouth. LVN C stated Resident #1 never tried to get up, was not able to use her call light and did not have the ability to make her needs know. LVN C stated no special supervision was required other than meeting all of the residents needs. LVN C stated prior to the incident Resident #1 did not have a change of condition. LVN C stated she last saw Resident #1 well at midnight, when she gave Resident #1 Tylenol. She stated she was supposed to check on the resident every 2 hours. She stated they were doing CPR between 2:00-3:00 a.m. LVN C stated EMS personnel told her they removed a Lidoderm Patch from Resident #1 during CPR. She stated they put it on the bed. LVN C stated she looked at it and agreed with EMS that it was a Lidoderm patch. She stated she could not see the working of the patch, but you could see remnant of the marker and date which were illegible. LVN C stated the patch had turned into a ball of goo and was very sticky. She described it as a blob. She stated when the Medical Examiner arrived, they took the blab with them. LVN C stated she was suspended from working pending the investigation. She stated she was required to complete all the in-services before being allowed to come back to work the next day. She stated she received hands on training for CPR, Heimlich maneuver, patch removal, medication administration, and AED and small objects and abuse. She stated she could not remember the others but had completed them all[PH6] . During an interview on 7/03/2025 at 4:18 p.m., CNA F stated she had no knowledge of the 676250 Page 5 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few incident. She stated after the situation she had received training on patches. She stated she was trained to notify the nurse if the patch wasn't where it was supposed to be or if they saw a patch off the resident. She stated she would go to the nurse if a patch needed to be removed. CNA F stated she received training on CPR and the Heimlich maneuver. She stated she was trained to look for small objects, look in resident mouths and do the Heimlich maneuver if someone is choking and to continue to do it until the object comes out and notify nurse. She stated she also received training on abuse neglect and definitions and would notify the ED immediately. During an interview on 7/06/2025 at 12:16 p.m. ADON G stated staff should document when the patch was put on and when it was taken off, usually in the evening. She stated Resident #1 was verbal but not understood and not able to make her needs known. She stated the resident spoke in word salad. ADON G stated the staff were trained to use the resident's non-verbal cues, monitor the resident, and look for any change of condition when caring for her. She stated monitoring at night would include ensuring the resident was observed every two hours during the night. She stated the resident herself did not have complaints and had no behaviors she was aware of. A ADON G stated she was not working when the choking incident occurred. She stated she found out about it the next morning when the DON called and asked to have a manager meeting to discuss the incident. ADON G stated she was told staff found a Lidocaine patch in Resident #1's throat. She stated the management pulled all resident orders, specifically residents who had orders for lidocaine patches. She stated the physicians came to the facility and reviewed their orders for residents and changed any orders for patches to creams if the resident allowed. ADON G stated she then assisted with in-serving staff. She stated staff had to actually perform CPR, use the AED. She stated they received training on abuse and neglect, what to do is someone was choking and what to do if they saw a resident put something in their mouth that wasn't supposed to be there. She stated the facility changed their policy for Lidocaine patches for two personnel to do the removals. She stated aides were instructed that while giving showers, if a patch comes off they are to take the patch to the nurse for documentation. ADON G stated the pharmacist came in and did education to the staff on patch use. ADON G stated only one resident remained on a Aspercream patch and was cognitively intact, all others had been changed to cream only. ADON G stated she did not participate in the investigation, just in staff in-services and education. ADON G stated a CPR drill was run, a actual simulation code. She stated each staff member received feedback and anyone who struggled repeated the drill until their response was adequate. ADON G stated each staff had to participate in using the AED, CPR training, crash cart review and assembly. She stated they had a choking vest, and a choking simulation was completed to assess staff on their choking skills. She stated she watched staff put on and properly remove a patch and a medication pass review was completed with staff. She stated all staff participated in the Heimlich skills. ADON G stated the abuse and neglect training was for all staff, who to contact, when and forms of abuse. She stated staff was instructed to report immediately, facility protocol and where the number for the Administrator (ED) was located. She stated this training was completed on 6/25/2025. She stated a few stranglers of staff who were on vacation were completed in the following days. She stated 99% of staff was completed on 6/25/2025. She stated it was important for staff to know and monitor the location of a patch, so staff knows where the patch is, in case it comes off so the facility does not experience a repeated incident. She stated the risk of a loose patch was choking. During an interview on 7/6/2025 at 1:33 p.m., CNA J stated they had completed multiple trainings post incident. He stated about CPR and how to help out in any way he could, preventing choking and what to do in the event of choking, which was to immediately help the resident, do the Heimlich maneuver, get help from the nurse if available, check their airway and start CPR 676250 Page 6 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few if not breathing. He stated he was trained to look for small objects and keep them out of reach so confused residents could not put them in their mouth. He stated if he saw a resident put something in their mouth, he would check their mouth and let the ADON or DON know immediately. He stated he learned about patches He stated he was trained on abuse and neglect he was instructed to notify the abuse coordinator right away and he would also notify his supervisor. During an interview on 7/06/2025 at 1:47 p.m,. the MDS Coordinator stated she was not in the facility during the incident and did not participate in the investigation or training. She stated she had received training herself which included adding monitoring of patch locations to residents' care plans who used a patch. She stated she also received training on monitoring new admissions for patch use and notification of the DON. She stated she was not aware of any oral behaviors exhibited by Resident #1 and was not aware of any resident in the facility who had oral fixation or oral behaviors. She stated her training also included CPR, code training, choking new patch process with two people as a witness, patch destruction out of the resident room, training of new staff and what to do if someone puts an small object in their mouth. She stated she would notify the ADON and DON so the resident could be assessed. She stated she received abuse/neglect training. She state any allegation or suspicious activity should be reported immediately to the Administrator (ED). She stated she would try to resolve/investigate immediately. She stated CPR training showed how to identify vital signs, initial assessment, rate of breaths/compressions, calling for help, AED, calling 911, teamwork, and Heimlich maneuver. During an interview on 7/06/2025 at 1:57 p.m., ADON H stated she was not at the facility when the incident occurred. She stated she received a call from the DON and came to the facility to assist. She stated she was told Resident #1 had coded and at the time they were not sure what happened. She stated later they learned she had choked on a Lidoderm patch. She stated she was not a witness and did not participate in the investigation. She stated she participated in education to staff post incident. She stated education included abuse neglect, a new system for patch monitoring, choking, CPR, monitoring patches, monitoring patch orders. She stated she taught the call right away to the Abuse Coordinator (ED) for abuse or neglect. She stated reviewed types of abuse, including the definition of neglect which was failure to provide essential care. She stated she told the staff all the multiple placed the ED number was located. ADON H stated choking hazards, Heimlich, CPR, code status, AED skills were all taught and reviewed as skills check off. She stated they reviewed how all departments could help in an emergency like calling 911, holding the doors, showing EMS where to co. She stated the skills check off included a return demonstration of skills by staff. She stated they taught the new procedure for logging of patches. Signing off their removal. She stated CNAs who see a patch off should notify the nurse. She stated if a resident had an altered mental status the nurse should see if they could obtain a different order and keep patches and small objects out of reach. During an interview on 7/06/2025 at 3:38 p.m., the DON stated on 6/24/2025 at 5:00 am she was notified about the incident involving Resident #1 and came to the facility. She stated she began the investigation, found out who the med-aide was which was LVN C and suspended her pending investigation. The DON stated began conducting interviews and notified the Administrator. The DON stated later that same day, they were updated from the Medical Examiner that the cause of death was accidental asphyxiation. She stated they were not told from what. The DON stated one nurse LVN C stated it was a Lidoderm Patch and LVN D stated it was a white substance. She stated the do not have confirmation from the ME that it was a Lidoderm patch. The DON stated the investigation revealed Resident #1 had no known behaviors of putting things in her mouth and had no change in behavior. She also had no change of condition prior to the event. The DON stated she asked staff and got input from therapy and even housekeeping if there was 676250 Page 7 of 8 676250 07/07/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few anyone, any resident who put items in their mouth. She stated no residents were identified. She stated they did safe surveys of residents and staff, and no abuse was identified. The DON stated from interviews she believed the facility handled the code appropriately. She stated she did not believe there was deficient practice. She stated they notified the pharmacist and she came to the facility to assist with training on patches and medication administration. The DON stated they reviewed their policy for patch administration and changed their protocols for how patches are handled. She stated they reviewed all orders and got rid of any patch orders that could be changed with the physicians. She stated they adjusted patch removal times on the MARS and included an entry for monitoring placement of the patches during the shifts. She stated all patches need to be disposed of outside of the resident rooms. The DON stated the Medical Director was notified and she informed him of the facilities plan. She stated he reviewed the plan and did not give any instruction, just said they were doing a good job. She stated the education of staff included what staff should do if they see a resident put a foreign object in their mouth. She stated they should notify the nurse and she should also be notified immediately to make sure the patient was safe. She stated someone should stay with the resident to keep them safe. The DON stated now everyone knows if a patch can not be located a through sear of the bedding and a head-to-toe assessment should be completed to try to locate the patch. She stated she protected residents from harm by reviewing charts and staff education. She stated she talks to residents and families about their concerns. She stated this was important for accountability. She stated the risk of an unaccounted for patch was possible choking. The DON stated from that point she proceeded with education of staff which included: -medication pass and observation, disposal of patches, patch protocol 40 of 41 staff completed. -patch protocols with two people as a witness, training CNA to question any patch they see in the room and to pick it up and bring it out of the room, CPR and ensuring everyone knows their part 83/83 nursing staff educated. -Following physician orders, new admission checklist in which any new admission with orders for a patch will be sent to her (DON) for review 32/32 licensed nurses completed. -choking and foreign object/small object in-service all 148/148 staff completed -Abuse/Neglect and Resident Rights- all 148/148 staff completedThe DON stated the training was mandatory and was completed on 6/24/2025-6/25/2025. During an interview on 7/06/2025 at 5:00 p.m., the Executive Director stated at the time of the incident he was out of state for a military obligation. He stated he was notified around 676250 Page 8 of 8